Wednesday, January 27, 2016
Friday, January 15, 2016
Written by Sheryl A. Riley, RN, OCN, CMCN
Originally published in the Journal of Managed Care Nursing
Originally published in the Journal of Managed Care Nursing
Readmissions and unplanned hospitalizations caused by side effects and poor symptom management falls on the shoulders of the patients, their families, and ancillary care systems, when it should be the responsibility of the treating physicians and their clinical teams. These steps can go a long way in keeping patients’ side effects under control and decreasing unplanned hospitalizations:
· Devote more time to patients and their families before treatment selection
· Improve patient education and teaching via conversations between the patient and a provider, care coach, or navigator to explain the risks and benefits of each treatment option
· Complete a thorough medical history and physical examination, and using functional or comorbid tools
· Strengthen patient–doctor communication regarding life-altering side effects
The goal of cancer treatment is to destroy cancer cells, whether through surgery, radiation, drug therapies, or a combination of these. During the course of these treatments, however, healthy cells can also be damaged or destroyed, leading to unpleasant side effects such electrolyte imbalance, dehydration, weight loss, fatigue, infection, lack of appetite, mouth sores, skin irritations, anemia, and depression. These side effects can frighten and even terrify patients if they have not been educated on what to expect; without proper guidance, they can also lead to emergency department visits and impact treatment adherence and completion.
Each patient with cancer responds differently to treatment, and in the last few years, researchers and providers have discovered better ways to predict, reduce, and even prevent side effects, leading in some cases to more tolerable treatments and better adherence. Controlling side effects and adverse drug reactions, and managing comorbid conditions and risks should be part of every patient’s cancer care program. Clinical, physical, functional, cognitive, and psychosocial assessments, along with education and self-care, are also cornerstones to better care, and can be improved by taking the following steps:
· Devoting more time to patients and their families before treatment selection
· Improving patient education and teaching via conversations between the patient and a provider, care coach, or navigator to explain the risks and benefits of each treatment option
· Completing a thorough medical history and physical examination, and using functional or comorbid tools (eg, Eastern Cooperative Oncology Group performance status, Charlson Comorbidity Index)
· Strengthening patient–doctor communication regarding life-altering side effects.
Patient education regarding treatment options and potential risks, benefits, and side effects is essential and should be prioritized in every oncology practice and cancer clinic. As oncologists and oncology nurses, we have an ethical responsibility to teach and reinforce the proactive management of side effects, but we are currently falling short in this area. Too many patients who should be managed by their physicians and nurses are being hospitalized for side effects and adverse drug reactions. Clinical and financial data analyses show that patients who are diagnosed with late-stage cancers, those diagnosed with cancer at higher acuity levels, and those who are receiving cancer treatments are hospitalized at a higher rate than those with early-stage disease.
In 2009, the Healthcare Cost and Utilization Project examined adult cancer hospitalizations and found that approximately 4.7 million hospitalizations of adult patients cancer-related; in 1.2 million (25%) of these, cancer was the principle diagnosis.1 This came at a cost of $20.1 billion (6%) in inpatient hospital costs. Patients who incurred the highest daily costs were patients with prostate ($4600), breast ($4100), and thyroid cancers ($3500). Furthermore, the most common cancer hospitalizations among men were for prostate cancer, secondary malignancies or metastatic cancer, and lung cancer; hospitalizations related to kidney cancer in adult men increased 40% from 2000 to 2009.1 The most common cancer hospitalizations among women were for secondary malignancies as well as breast and lung cancers. Bronchus, lung, and colon cancer, as well as secondary malignancies, accounted for more than one-third of the total cost of hospital stays for cancer.
In a separate study that same year, the Healthcare Cost and Utilization Project examined common cancer hospitalizations again; investigators assessed hospital readmissions for cancer surgery in teaching versus nonteaching hospitals in New York. Thirty-day readmissions were assessed from 21,945 admissions for cancer surgery, and the overall readmission rate was 9.3%, with 11.2% of readmissions occurring in nonteaching hospitals, and 8.6% occurring in teaching hospitals.2 Factors that increased the risk for 30-day readmission for a preventable cause among patients with cancer were male sex, undergoing surgery at a nonteaching hospital, African American race, and certain comorbidities.
Four years later, little had changed. In a study by Brown and colleagues, Medicare estimated that the cost of readmission was $17 billion annually, and investigators showed that more than 50% of patients who were discharged after surgery had died or were rehospitalized <1 year after discharge.3 The same study found that patients with cancer receiving medical services were readmitted more than patients with cancer receiving surgical services, and noted that National Cancer Institute-designated comprehensive cancer centers had a higher readmission rate than non-designated cancer centers.
Overall, almost one-third of patients were readmitted to hospitals ≤7 days after discharge; 33% of these readmissions were the result of potentially preventable side effects (eg, nausea, vomiting, dehydration, and postoperative pain).
A study from October 2014 showed that unplanned hospitalization rates among patients with gastrointestinal cancers are higher than some other cancers, but, most importantly, are potentially preventable.4 The study used the Texas Cancer Registry and Medicare claims data for in-hospital admissions from 30,199 patients with gastrointestinal cancer aged ≥66 years. The rate of unplanned hospitalization was 58.1%, and 55.9% of these hospitalizations occurred within the first year of cancer diagnosis. Moreover, the top reasons for unplanned hospitalization—fluid and electrolyte disorders, intestinal obstruction, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and bronchiectasis—were considered potentially preventable, and lead author Joanna-Grace M. Manzano, MD, noted that these comorbidities “may help identify areas of focus for improvement or intervention.” Further analysis revealed that patients with esophageal, gastric, pancreatic, and rectal cancers, as well as patients with regional and distant diseases, were at higher risk for unplanned hospitalization.
Another prospective study that examined drug-related problems and their correlation with unplanned hospitalizations focused on 2 oncology units with patients diagnosed with solid tumors or lymphoma.5 Results were described as predictable; the incidence of unplanned hospitalizations associated with drug-related problems was 12.4%, approximately half of which were potentially preventable events. The study revealed that the majority of the admissions related to drug-related problem were adverse drug reactions (N = 155, 94.5%), moderately severe (N = 155, 94.5%), and probably or definitely preventable (N = 86, 52.4%). It is also important to note that febrile neutropenia was the most common adverse drug reaction, and drug combinations including antihypertensives and long-term corticosteroids increased the risk of potential drug–drug interactions.
The key points in most studies were that many of the unplanned hospitalizations that were reported were potentially preventable and were related to patients’ high comorbidity scores. This means that oncologists do not have a clear picture of their patients—or their patients’ expectations—before or while making decisions about the most appropriate cancer treatment. Completing full clinical histories and examinations, as well as cognitive, functional, and psychosocial assessments should not be overlooked or taken for granted. Too often, pretesting and full clinical assessments of patients’ histories and care expectations are overlooked or not revisited once treatment is initiated.
Treating physicians (ie, oncologists, primary care physicians, and other specialists) should recognize that elderly patients who have gastrointestinal cancer are vulnerable to unplanned hospitalizations. Knowing that elderly patients with gastrointestinal cancer are prone to more frequent unplanned hospitalizations, healthcare providers should promote efforts to improve the coordination of care among everyone involved in caring for them. Patients would likely benefit from continued, close follow-up with their oncologist, oncology care manager, or even their primary care physicians during treatment and for years to come.
All of this research and information affirms that the burden of readmissions and unplanned hospitalizations caused by side effects and poor symptom management falls on the shoulders of the patients, their families, and ancillary care systems, when it should be the responsibility of the treating physicians and their clinical teams.
Improving side-effect management for patients is a goal for which every oncology clinic and practice should strive. Proactive side-effect education and emotional support for patients and their families, as well as frequent, comprehensive follow-ups and monitoring before, during, and after treatment are essential. These steps can go a long way in keeping patients’ side effects under control and decreasing unplanned hospitalizations. In addition, the use of clinical assessment tools to better understand the patient’s comorbid history, physical health, cognitive function, mental and emotional health, as well as care expectations should be a key part of every oncology practice. Readmissions and unplanned hospitalizations play a role in decreasing a patient’s survival, and oncology care teams must improve side-effect management to prevent this.
1. Price RA, Stranges E, Elixhauser A. HCUP Statistical brief 125: Cancer hospitalization for adults, 2009. www.hcup-us.ahrq.gov/reports/statbriefs/sb125.pdf. Published February 2012. Accessed June 4, 2015.
2. Kuznar W. Causes of hospital readmissions of patients with cancer. Am Health Drug Benefits. 2013;6:22-23.
3. Brown EG, Burgess D, Li C, et al. Hospital readmissions: necessary evil or preventable target for quality improvement. Ann Surg. 2014;260:583-591.
4. Manzano JG, Luo R, Elting LS, et al. Patterns and predictors of unplanned hospitalization in a population-based cohort of elderly patients with GI cancer. J Clin Oncol. 2014;32:3527-3533.
5. Chan A, Soh D, Ko Y, et al. Characteristics of unplanned hospital admissions due to drug-related problems in cancer patients. Support Care Cancer. 2014;22:1875-1881.